How should I initially evaluate and manage back pain in an 80‑year‑old man with prior ischemic stroke, left renal cell carcinoma, hypertension, and hyperlipidemia?

Initial Evaluation and Management of Back Pain in an 80-Year-Old Man with Prior Stroke and Renal Cell Carcinoma

This patient requires immediate focused assessment for "red flag" conditions—particularly metastatic disease from his known kidney cancer—before any conservative management is initiated, and imaging should be obtained urgently given his cancer history rather than waiting for a trial of conservative therapy.

Critical Red Flag Assessment

This patient's history of left renal cell carcinoma fundamentally changes the approach to back pain evaluation. You must immediately assess for metastatic disease, as vertebral malignancy has a 0.7% prevalence in general back pain populations but jumps to 9% posttest probability in patients with prior malignancy 1. The presence of cancer history carries a positive likelihood ratio of 14.7 for vertebral malignancy 1.

Immediate History and Physical Examination Focus

Conduct a targeted evaluation specifically assessing for 2, 3, 1:

• Neurologic deficits: Motor weakness at multiple levels, saddle anesthesia, urinary retention, or fecal incontinence (cauda equina syndrome has 0.04% prevalence but requires emergency intervention) 1
• Constitutional symptoms: Unexplained weight loss, failure to improve with any conservative measures, night pain, or pain at rest 1
• Pain characteristics: Midline tenderness (suggests compression fracture, 4% prevalence), radicular distribution down the leg (suggests disc herniation), or bilateral leg symptoms with pseudoclaudication (spinal stenosis, 3% prevalence) 1
• Functional impact: Ability to ambulate, progressive weakness (a critical red flag in cancer patients) 4

Laboratory Evaluation

Obtain baseline studies including 2:

• Serum creatinine (particularly important given his single kidney status)
• Hemoglobin, leukocyte and platelet counts
• Lactate dehydrogenase
• Serum-corrected calcium
• Alkaline phosphatase (elevated in bone metastases)

Imaging Strategy

Unlike typical back pain patients where imaging is deferred, this patient requires immediate advanced imaging due to his cancer history 1. The standard recommendation against routine imaging in nonspecific low back pain does not apply when red flags are present 2, 3.

Recommended Imaging Approach

Order MRI of the lumbar spine without contrast as the initial study 1. MRI is preferred over CT because it provides superior soft tissue visualization, avoids radiation exposure, and better detects both bone metastases and epidural disease 1.

• Renal cell carcinoma commonly produces purely lytic skeletal metastases that can cause vertebral collapse 4
• RCC can present with intramedullary spinal cord lesions in rare cases 5
• Plain radiographs are inadequate—case reports document negative plain films that missed significant metastatic disease detected only on MRI 4

If MRI reveals concerning lesions, consider bone scan to evaluate for additional skeletal metastases 5.

Pain Management Considerations

While awaiting imaging results, pain control must account for this patient's multiple comorbidities:

Avoid NSAIDs in This Patient

NSAIDs are contraindicated or require extreme caution given 2:

• Age >60 years (high risk for renal, GI, and cardiac toxicities)
• Single kidney status (compromised renal reserve)
• History of stroke (cardiovascular disease increases cardiac toxicity risk)
• Hypertension (NSAIDs can worsen blood pressure control)

Preferred Analgesic Approach

Use acetaminophen 650 mg every 4-6 hours (maximum 3-4 g/day) as first-line therapy 2. This avoids the renal, cardiovascular, and bleeding risks of NSAIDs in this high-risk patient.

If acetaminophen provides insufficient relief and imaging excludes surgical emergencies, consider short-term opioid therapy rather than NSAIDs given his contraindications 2.

Management Algorithm Based on Imaging Results

If Metastatic Disease is Identified

• Urgent oncology and neurosurgery consultation
• Radiation oncology evaluation for palliative radiotherapy
• Assess for spinal instability requiring surgical stabilization
• Systemic therapy discussion with medical oncology

If No Metastatic Disease but Mechanical Pathology Found

• Radiculopathy or spinal stenosis: Consider epidural steroid injection if conservative management fails after 6 weeks 3, 1
• Compression fracture: Evaluate for osteoporosis treatment, consider vertebroplasty/kyphoplasty consultation

If Imaging is Unremarkable

• Reassess for nonspinal causes (abdominal aortic aneurysm given age and cardiovascular risk factors)
• Consider conservative management with activity modification and acetaminophen
• Physical therapy referral after excluding serious pathology

Critical Pitfalls to Avoid

• Never defer imaging in a patient with known malignancy and new back pain—the standard "wait 6 weeks" approach does not apply 1
• Do not use NSAIDs in this patient despite their effectiveness in typical back pain, given his age, single kidney, stroke history, and hypertension 2
• Do not miss cauda equina syndrome—ask specifically about urinary retention and saddle anesthesia, as delayed recognition causes permanent neurologic disability 1
• Progressive muscle weakness is a red flag requiring immediate advanced imaging, even if initial plain films appear normal 4

Blood Pressure Management Context

Given his stroke history, maintain awareness that pain itself can elevate blood pressure 2. However, aggressive blood pressure reduction is not indicated unless diastolic BP >120 mmHg or systolic >220 mmHg, as overly aggressive treatment could reduce perfusion in watershed zones 2.